An Article on Prescription Errors and the consequences

Prescription Errors

This article is a very long read, but it is worth it, it is very enlightening and would be worth your time.

PRESCRIPTION ERRORS; A COMMON MENACE TO HEALTHCARE DELIVERY

“Let’s say a physician writes a prescription for colchicine and accidentally orders ’10.0mg’ when he ought to have ‘1.0mg’. That’s a tiny decimal error, a mistake even the best doctor could make. It could be catastrophic for the patient; that’s the reason a pharmacist should be at alert, always cross checking and making necessary adjustments”. A versed physician advised.

“I presented the piece to the already somnolent pharmacist, she blinked her eyes a thousand times, and I understood the words and figures weren’t visible to her. Inspired by laziness; she returned the note, and brought out a myriad of formulations from the counter. She wrote the crass by heart on the wrap, and my mom bore the brunt of her non-chalant attitude. As preposterous as it is, she chose her sleep over my mom’s safety”. A victim lamented.

This and many more cases have been reported across the globe. Statistics show that thousands of deaths occur each year because of prescription, dispensing and medical errors. Reducing medication errors have become a topic of top priority in our nation, with primary emphasis on improving patient safety. For decades, minimizing adverse drug events and prescription error has been a goal in health care. In fact, according to the report of the Institute of Medicine (2014); between 44,000 and 98,000 people die in hospitals as a result of medical errors this, according to major studies could have been prevented. This dilemma has led to lack of confidence in the health sector (thus preference to Ayurveda decoctions), belittling the pharmacy profession (a ridicule to professionalism), endangering life, worsening patient condition, reducing the therapeutic effectiveness of drugs and wasting valuable resources.

PRESCRIBING AND PRESCRIPTION ERRORS

A prescription is a written document which contains list of drugs and direction on how they are to be taken by the patient in a hospital (Kohn et al. 1999). It is a piece of paper on which a doctor writes what medicine a sick person should have, so that they can get it from a pharmacist (Advanced Learners’ Longman Dictionary of Contemporary English). Prescription errors are problems encountered, identified in the process of dispensing that might interfere with the dispensing of prescriptions; prescription with incorrect information; or be potentially harmful to the patients, such as drug-drug interactions, inappropriate doses or directions for use, contraindications, adverse drug reactions, allergy to drug and duplication (Rupp 1997).

It is imperative that a prescription be clear, it should be legible and indicate precisely what should be given. When this is in doubt, it is ethical and the responsibility of the trained pharmacist to source, correct and adjusts before dispensing.

A prescription which indicates four 500mg tablets of paracetamol to be taken three times daily (t.i.d) for a 12year old child is an obvious example of a prescription error as it is clearly an overdose. Hence, it is imperative that the community pharmacist verify every prescription before dispensing.

……the pharmacist and not the physician would be held responsible for this error… (EMDEX 2017).

THE ROLE OF THE LEARNED INTERMEDIARY (PHARMACIST) IN ENSURING PATIENT SAFETY.

The victim’s lamentation in the preamble depicts the indispensable role of a community pharmacist in ensuring appropriate adoption of drug therapy. Community pharmacists are the health professionals most accessible to the public and most prescription error could be reversed with the presence of a sensitive pharmacist.

Nobody knows more about drugs and medications than pharmacists do—not doctors, not nurses, not anyone. The basic duty of a trained pharmacist is to check prescriptions from physicians before dispensing the medication to the patient to ensure that the patient doesn’t receive the wrong drugs or take an incorrect dose of medicine. Hence, the responsibility of ensuring rational use of drugs rests on the shoulder of the dispensing pharmacist.

Prevention of errors at the dispensing stage is one of the most important step in preventing the doggone ugly consequences of a slip in prescribing. This is a responsibility of every health practitioner with emphasis on the pharmacist ( a careless slip by dispensers is unethical and should be reduced to the bearest minimum). This is a call we must obey---a call to curb the menace of prescription error!

REFERENCES

EMDEX(june 2016-may 2017 edition) vol.1, general advice to prescribers, pages 33 -39.

RUPPMT(1997) screening for prescribing errors. Am pharm. 1997; NS31:71-8 (PUBMED).

Kohn westein MPD,Herings RMC, Leufkens HGM(1999). Determinants of pharmacists interventions linked to prescription processing. Pharm world science 200l;23;98-101[pubmed].